gasexchange

Archives Airway Anesthesiology Covid-19 Decision making Education Evidence based medicine Feature Mental models metajournal News Obstetrics Pediatrics Perioperative medicine Sugammadex Technology Wisdom

Articles and metajournal Notes

A great way to capture and share knowledge gleaned from the evidence is with...

You may have noticed that suggested articles arriving in your emailed metajournal or appearing in online article lists have a pearl or summary above the abstract. My aim is to make keeping up to date and understanding the current literature even more time efficient.

You can add your own notes to any article or abstract you read — both to help you capture the most actionable 'take-away' message, and also to share your wisdom with others. Simple scroll down below the article abstract to find a list of notes and a text-box for you to add your own.

Notes can be either pearls, summaries or comments, depending on the type of information you want to share.

Two examples of articles with notes to get you started:

Jump in and share your wisdom!

If sugammadex is the answer what is the question?

Sugammadex (Bridion®) is a remarkable drug. It also has a cool name. The anaesthesia community has moved very quickly to embrace the potential of this first and only 'selective relaxant binding agent' (SRBA), despite it's considerable cost.

"Sugammadex is likely the most exciting drug in clinical neuromuscular pharmacology since the introduction of atracurium and vecuronium in the middle 1980s." - Miller RD 1

Novel pharmacology and a cool name are however insufficient reasons alone to alter our practice. There is a certain lack of clarity in the community and literature as to where sugammadex fits into anaesthesia practice and to what extent it should alter how we currently manage muscle relaxation and reversal. There has also been very limited discussion of the unintended consequences of a shift to rocuronium-sugammadex based techniques over other neuromuscular drugs.

There is no doubt that sugammadex offers a new and improved way of reversing aminosteroid muscle relaxation, in particular that from rocuronium.  The speed at which it reverses even profound neuromuscular blockade is incredible and potentially life saving. Sugammadex‘s onset is 10 times faster than neostigmine and three times faster than edrophonium.2

Read more...


  1. Miller RD. Sugammadex: an opportunity to change the practice of anesthesiology? Anesth Analg. 2007 Mar;104(3):477-8. 

  2. Sacan O, White PF, Tufanogullari B, Klein K. Sugammadex reversal of rocuronium-induced neuromuscular blockade: a comparison with neostigmine-glycopyrrolate and edrophonium-atropine. Anesth Analg. 2007 Mar;104(3):569-74. 

Neuromuscular myths: We need to do better

The rise of sugammadex has lead me down a path looking into wider aspects of my own neuromuscular blocking drug (NMBD) use. The evidence for NMBD use, monitoring and reversal is interesting, both for how consistently the same messages have been repeated over the past three decades – and for how little we have improved our practice in spite of mounting evidence demanding that we should.1

I need to do better and you probably also need to do better with how we manage NMBDs.

What is PORC?

Post-operative residual curarisation (PORC) or residual paralysis, refers to persisting neuromuscular blockade in a patient after extubation. It is considered present when the Train-of-four (TOF) ratio is less than 0.9, usually measured in recovery or the post anesthesia care unit (PACU).

The historical comparison of studies investigating PORC is difficult because for many years a TOF ratio of 0.7 was considered the cutoff value for PORC. Volunteers given d-tubocurarine had normal vital capacity and inspiratory force when the TOFR recovered above 0.7. Then in the mid-1990s a TOF ratio of 0.8 was used in studies investigating PORC.

Now in the 21st century a TOFR 0.9 is considered the cut-off for defining PORC. A TOFR 0.9 has been chosen because consequences of residual paralysis, such as pharyngeal dysfunction and impairment of respiratory function have been shown below this TOF ratio.

Read more...


  1. Case in point: Donati F. Neuromuscular monitoring: what evidence do we need to be convinced? Anesth Analg. 2010 Jul;111(1):6-8. (pubmed

Wow! A great response from our beta users!

A big thank you to all those members of metajournal who signed up for our special beta pricing – I am humbled by your support!

Metajournal has been in open beta for only a few weeks, yet the number of articles we have indexed and the number of doctors using metajournal continues to grow.

While metajournal's supernatural-ability to suggest interesting articles is the core of the service, I have many new features currently being worked on – and even more on the drawing board. I am most excited to soon be adding the ability to add notes to articles: summaries, pearls and comments to share with the rest of the metajournal community.

Our special beta pricing will only continue for another couple of weeks, so sign up now for a paid account to save $50 on your first year subscription – and so keep up to date!

On Anaesthesia and Simplicity

It is easy to lose sight of the core of the practice of anaesthesia. As a profession we are easily seduced and distracted by the new and exciting; quickly forgetting that satisfyingly favourable outcomes for our patients occur not because of the advances in the technology and pharmacology of anaesthesia, but rather are owed to our training and performance as anaesthetists and anaesthesiologists managing that complex system.

Our ability to understand the complex model of patient, surgeon, drugs and scalpel; to resist distraction by the blinkenlights of whatever new device has been dragged in by the friendly equipment rep; the exciting kinetics of the latest drug; or the new ventilator modes on the anaesthetic machine - our ability to conceptually simplify these things and achieve good outcomes is at the core of what we do.

Read more...

What will the 'Medical Journal of You' look like?

Start your free 21 day trial now.

We guarantee your privacy. Your email address will not be shared.